Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in an emergency department is assisting with the care of a client who is unconscious and has trauma to multiple systems following a motor vehicle crash. Which of the following actions should the nurse take first?
A. Airway protection
This action is correct because airway protection is the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's airway patency, breathing, and oxygenation, and intervene as needed to secure and maintain the airway. The nurse should also monitor the client for signs of aspiration, bleeding, or obstruction, and suction the airway as needed.
B. Stabilizing cardiac arrhythmias
This action is incorrect because stabilizing cardiac arrhythmias is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's circulation, blood pressure, and pulse, and intervene as needed to treat any arrhythmias, shock, or hemorrhage. However, this is not a priority over the client's airway, which is essential for survival.
C. Preventing musculoskeletal disability
This action is incorrect because preventing musculoskeletal disability is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's mobility, sensation, and alignment, and intervene as needed to prevent or treat any fractures, dislocations, or nerve injuries. However, this is not a priority over the client's airway, which is essential for survival.
D. Decreasing intracranial pressure
This action is incorrect because decreasing intracranial pressure is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's level of consciousness, pupillary response, and neurological status, and intervene as needed to prevent or treat any increased intracranial pressure, cerebral edema, or brain injury. However, this is not a priority over the client's airway, which is essential for survival.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Lpn Fundamentals Proctored Exam 1. Take the full exam now
Full Explanation
Choice A reason: This action is correct because airway protection is the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's airway patency, breathing, and oxygenation, and intervene as needed to secure and maintain the airway. The nurse should also monitor the client for signs of aspiration, bleeding, or obstruction, and suction the airway as needed.
Choice B reason: This action is incorrect because stabilizing cardiac arrhythmias is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's circulation, blood pressure, and pulse, and intervene as needed to treat any arrhythmias, shock, or hemorrhage. However, this is not a priority over the client's airway, which is essential for survival.
Choice C reason: This action is incorrect because preventing musculoskeletal disability is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's mobility, sensation, and alignment, and intervene as needed to prevent or treat any fractures, dislocations, or nerve injuries. However, this is not a priority over the client's airway, which is essential for survival.
Choice D reason: This action is incorrect because decreasing intracranial pressure is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's level of consciousness, pupillary response, and neurological status, and intervene as needed to prevent or treat any increased intracranial pressure, cerebral edema, or brain injury. However, this is not a priority over the client's airway, which is essential for survival.
Similar Questions
A nurse is working with an RN to admit a new client. Which of the following steps of the nursing process is the nurse using when assisting to formulate goals for a positive outcome?
A. Planning
This statement is correct because planning is the step of the nursing process that involves formulating goals and outcomes for a positive outcome. The nurse and the RN should collaborate with the client and other members of the healthcare team to identify the client's needs, priorities, and preferences, and develop a plan of care that is realistic, measurable, and client centered.
B. Evaluation
This statement is incorrect because evaluation is the step of the nursing process that involves measuring the effectiveness of the plan of care and the achievement of the goals and outcomes. The nurse and the RN should compare the actual results with the expected results, and determine if the plan of care needs to be modified, continued, or terminated.
C. Data collection
This statement is incorrect because data collection is the step of the nursing process that involves gathering information about the client's health status, history, and environment. The nurse and the RN should use various sources and methods of data collection, such as interviewing, observing, examining, and reviewing records, and organize and document the data in a systematic and accurate way.
D. Implementation
This statement is incorrect because implementation is the step of the nursing process that involves carrying out the plan of care and providing the interventions. The nurse and the RN should perform the actions that are necessary to achieve the goals and outcomes, such as administering medications, providing education, or coordinating referrals, and document the interventions and the client's response.
Full Explanation
Choice A reason: This statement is correct because planning is the step of the nursing process that involves formulating goals and outcomes for a positive outcome. The nurse and the RN should collaborate with the client and other members of the healthcare team to identify the client's needs, priorities, and preferences, and develop a plan of care that is realistic, measurable, and client centered.
Choice B reason: This statement is incorrect because evaluation is the step of the nursing process that involves measuring the effectiveness of the plan of care and the achievement of the goals and outcomes. The nurse and the RN should compare the actual results with the expected results, and determine if the plan of care needs to be modified, continued, or terminated.
Choice C reason: This statement is incorrect because data collection is the step of the nursing process that involves gathering information about the client's health status, history, and environment. The nurse and the RN should use various sources and methods of data collection, such as interviewing, observing, examining, and reviewing records, and organize and document the data in a systematic and accurate way.
Choice D reason: This statement is incorrect because implementation is the step of the nursing process that involves carrying out the plan of care and providing the interventions. The nurse and the RN should perform the actions that are necessary to achieve the goals and outcomes, such as administering medications, providing education, or coordinating referrals, and document the interventions and the client's response.
A nurse is teaching a client about the benefits of an electronic health record. Which of the following information should the nurse include in the teaching?
A. Allows client access to their medical record electronically at any time
Choice A: This is the correct answer. An electronic health record (EHR) is a digital version of a client's medical history and other health information that can be accessed by authorized providers and the client. A personal health record (PHR) is a subset of an EHR that allows the client to view and manage their own health information, such as medications, allergies, test results, and appointments. A PHR can enhance the client's satisfaction, engagement, and empowerment in their health care.
B. Provides providers client information to track for research studies
Choice B: This is incorrect. Provides providers client information to track for research studies is not a benefit of an electronic health record, but a potential use of it. EHRs can facilitate health research by providing large and diverse data sets that can be analyzed for various purposes, such as clinical trials, epidemiology, and quality improvement. However, this use of EHRs must comply with ethical and legal standards, such as informed consent, privacy, and confidentiality.
C. Grants significant other access to client information
Choice C: This is incorrect. Grants significant other access to client information is not a benefit of an electronic health record, but a matter of the client's preference and consent. EHRs must protect the client's privacy and confidentiality rights, and only disclose their information to authorized parties, such as health care providers, insurers, or public health agencies. The client can choose to share their information with their significant other or anyone else, but they must give explicit permission to do so.
D. Coordinates all healthcare client has received into one platform
Choice D: This is incorrect. Coordinates all healthcare client has received into one platform is not a benefit of an electronic health record, but a goal of it. EHRs aim to improve the coordination and continuity of care by allowing multiple providers to access and update the same information, enabling real-time collaboration, and providing decision support tools. However, this goal is not fully achieved yet, as there are still challenges and barriers to the interoperability and integration of EHRs across different settings and systems.
Full Explanation
Choice A: This is the correct answer. An electronic health record (EHR) is a digital version of a client's medical history and other health information that can be accessed by authorized providers and the client. A personal health record (PHR) is a subset of an EHR that allows the client to view and manage their own health information, such as medications, allergies, test results, and appointments. A PHR can enhance the client's satisfaction, engagement, and empowerment in their health care.
Choice B: This is incorrect. Provides providers client information to track for research studies is not a benefit of an electronic health record, but a potential use of it. EHRs can facilitate health research by providing large and diverse data sets that can be analyzed for various purposes, such as clinical trials, epidemiology, and quality improvement. However, this use of EHRs must comply with ethical and legal standards, such as informed consent, privacy, and confidentiality.
Choice C: This is incorrect. Grants significant other access to client information is not a benefit of an electronic health record, but a matter of the client's preference and consent. EHRs must protect the client's privacy and confidentiality rights, and only disclose their information to authorized parties, such as health care providers, insurers, or public health agencies. The client can choose to share their information with their significant other or anyone else, but they must give explicit permission to do so.
Choice D: This is incorrect. Coordinates all healthcare client has received into one platform is not a benefit of an electronic health record, but a goal of it. EHRs aim to improve the coordination and continuity of care by allowing multiple providers to access and update the same information, enabling real-time collaboration, and providing decision support tools. However, this goal is not fully achieved yet, as there are still challenges and barriers to the interoperability and integration of EHRs across different settings and systems.
A nurse is collecting data on a client who has had diarrhea for several days. Which of the following findings should the nurse expect?
A. Rigid abdomen
This statement is incorrect because a rigid abdomen is not a common finding for a client who has had diarrhea for several days. A rigid abdomen may indicate peritonitis, which is an inflammation of the abdominal lining, usually caused by an infection or a perforation of an organ. A client with peritonitis may also have severe abdominal pain, fever, nausea, and vomiting.
B. Dehydration
This statement is correct because dehydration is a common finding for a client who has had diarrhea for several days. Dehydration occurs when the body loses more fluid than it takes in, which can happen with frequent and watery stools. A client with dehydration may also have dry mouth, thirst, decreased urine output, dark urine, low blood pressure, increased heart rate, and confusion.
C. Hypothermia
This statement is incorrect because hypothermia is not a common finding for a client who has had diarrhea for several days. Hypothermia occurs when the body temperature drops below 35°C (95°F), usually due to exposure to cold environments or inadequate clothing. A client with hypothermia may also have shivering, slow breathing, slow pulse, drowsiness, and loss of consciousness.
D. Decreased bowel sounds
This statement is incorrect because decreased bowel sounds are not a common finding for a client who has had diarrhea for several days. Decreased bowel sounds may indicate ileus, which is a temporary paralysis of the intestinal movement, usually caused by surgery, medication, or inflammation. A client with ileus may also have abdominal distension, constipation, nausea, and vomiting.
Full Explanation
Choice A reason: This statement is incorrect because a rigid abdomen is not a common finding for a client who has had diarrhea for several days. A rigid abdomen may indicate peritonitis, which is an inflammation of the abdominal lining, usually caused by an infection or a perforation of an organ. A client with peritonitis may also have severe abdominal pain, fever, nausea, and vomiting.
Choice B reason: This statement is correct because dehydration is a common finding for a client who has had diarrhea for several days. Dehydration occurs when the body loses more fluid than it takes in, which can happen with frequent and watery stools. A client with dehydration may also have dry mouth, thirst, decreased urine output, dark urine, low blood pressure, increased heart rate, and confusion.
Choice C reason: This statement is incorrect because hypothermia is not a common finding for a client who has had diarrhea for several days. Hypothermia occurs when the body temperature drops below 35°C (95°F), usually due to exposure to cold environments or inadequate clothing. A client with hypothermia may also have shivering, slow breathing, slow pulse, drowsiness, and loss of consciousness.
Choice D reason: This statement is incorrect because decreased bowel sounds are not a common finding for a client who has had diarrhea for several days. Decreased bowel sounds may indicate ileus, which is a temporary paralysis of the intestinal movement, usually caused by surgery, medication, or inflammation. A client with ileus may also have abdominal distension, constipation, nausea, and vomiting.